Pennsylvania Department of Health
POCOPSON HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 55 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


POCOPSON HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on February 26, 2025, at Pocopson Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000

Facility ID #162002
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 25 & 26, 2025, it was determined that Pocopson Home was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a five-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0100

28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met.

35 P.S. 448.808. Issuance of license.

(a)STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered.

Based on document review, observation and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Review of documentation, observation and interview on February 25, 2025, between 9:45 AM and 11:00 AM, revealed the facility lacked documentation of annual testing and inspection of installed Carbon Monoxide Alarms, per manufacture's instructions, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. Facility could not provide manufacture's instructions.

Interview at the time of the exit conference with the Administrator and the Building and Grounds Director February 26, 2025, at 1:00 PM, confirmed the facility lacked documentation of annual inspections were done, per manufacture's instructions.

2. Observation and interview on February 25, 2025, between 9:45 AM and 12:15 PM, revealed the facility could not verify Carbon Monoxide Alarms could be heard by staff on duty, in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.

Interview at the time of the exit conference with the Administrator and the Building and Grounds Director February 26, 2025, at 1:00 PM, confirmed facility could not verify Carbon Monoxide Alarms could be heard by staff on duty.

Plan of Correction - To be completed: 03/11/2025

1. Hardwired carbon monoxide alarms are being installed in the boiler room, the laundry, and the kitchen area. These detectors will be connected to our fire panel and will be tested and inspected yearly by our alarm company.

2. Hardwired carbon monoxide alarms are being installed in the boiler room, the laundry, and the kitchen area. These detectors will be connected to our fire panel and alarm will be heard throughout the building.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

NFPA 101 STANDARD Building Construction Type and Height:

Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0161
Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component.

Findings include:

1. Observation on February 25, 2025, at 10:00 AM, revealed the facility is a five-story, Type II (000), unprotected noncombustible structure, with a basement. This type of construction is not permitted to be greater than two stories in height, with sprinkler protection.

Interview at the time of the exit conference with the Administrator and the Building and Grounds Director February 26, 2025, at 1:00 PM, confirmed the construction type is not allowed in health care.

Plan of Correction - To be completed: 03/06/2025

The Facility wishes to have DSI conduct the FSES survey. Pocopson Home has submitted a TLW request to your office.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain sprinkler piping to be free of extraneous weight, affecting four of seventeen smoke compartments within the component.

Findings include:

1. Observation on February 26, 2025, between 9:40 AM and 10:35 AM, revealed various items laying across sprinkler piping system and attached to sprinkler bracket, above the ceiling, at the following locations:

a. 9:40 AM, 3rd floor, Jones, outside Therapy Gym, above ceiling, wires;
b. 9:45 AM, 3rd floor, Jones, by Resident Room 319, above ceiling, multiple wires and rigid conduit;
c. 9:48 AM, 3rd floor, Jones, by Nurses' Station, above ceiling, multiple wires;
d. 10:15 AM, by 2nd floor, above Nurses' Station, 2 front, above ceiling, multiple wires;
e. 10:35 AM, 1st floor, by Lounge 12, above ceiling, multiple wires.

Interview at the time of the exit conference with the Administrator and the Building and Grounds Director February 26, 2025, at 1:00 PM, confirmed various items laying across sprinkler system pipes.

Plan of Correction - To be completed: 03/06/2025

1. All wires laying across the sprinkler pipes laying across sprinkler piping system and attached to sprinkler bracket, above the ceiling, at the following locations:
a. 3rd floor, Jones, outside Therapy Gym, above ceiling, multiple wires.
b. 3rd floor, Jones, by Resident Room 319, above ceiling, multiple wires and rigid conduit.
c. 3rd floor, Jones, by Nurses' Station, above ceiling, multiple wires.
d. 2nd floor, above Nurses' Station, 2 front, above ceiling, multiple wires.
e. 1st floor, by Lounge 12, above ceiling, multiple wires.

The Maintenance department staff will inspect various areas of the sprinkler system for proper clearance and integrity during their weekly maintenance rounds. Audit results will be reported to the Quality Improvement/Infection Control Committee.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility lacked documentation verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component.

Findings include:

1. Review of documentation on November 25, 2025, between 9:15 AM and 11:00 AM, failed to provide documentation of the 4-year fire damper exercise and maintenance.

Interview at the time of the exit conference with the Administrator and the Building and Grounds Director February 26, 2025, at 1:00 PM, confirmed the facility lacked documentation of the 4-year fire damper exercise and maintenance.

Plan of Correction - To be completed: 03/06/2025

1. All fire dampers have been visually inspected and exercised. Damper inspection sheets have been developed and will be maintained.

The Maintenance department has added damper maintenance and exercise to the preventative maintenance schedule every 4 years.

Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

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